Description:

RTOG 0825 Phase III GBM Salvage Treatment Summary Form (SF) Temozolomide and Radiation Therapy With or Without Bevacizumab in Treating Patients With Newly Diagnosed Glioblastoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5AE2A23C-8AF1-6A8B-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5AE2A23C-8AF1-6A8B-E044-0003BA3F9857

Keywords:
Versions (4) ▾
  1. 8/26/12
  2. 1/9/15
  3. 1/9/15
  4. 1/9/15
Uploaded on:

January 9, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Brain and Central Nervous System Tumors NCT00884741 Treatment - RTOG 0825 Phase III GBM Salvage Treatment Summary Form (SF) - 2797440v1.0

INSTRUCTIONS: Submit this form at the completion of each cycle of salvage treatment. Dates are to be recorded as mm-dd-yyyy unless otherwise specified

Module 1
Amended Data (INSTRUCTIONS: Complete form on web to unblind the protocol treatment arm)
Assessment
cm
Kg
m2
Karnofsky Performance Status (Use 9 if unknown)
Neurologic function
Disease Progression
Salvage treatment being reported
Is protocol chemotherapy continuing?
Unnamed 3
Was dose reduced more than 20%
Reason for Treatment Modification
Reason Treatment Ended
Protocol Specific Adverse Event Evaluation
Were there any hemorrhage events during this report period
CTC AE Attribution Code
CTC AE Attribution Code
SAE report submitted
SAE report submitted
seconds
seconds
seconds
seconds
seconds
1000/uL
Protocol Specific Adverse Event Evaluation
Were there any study-specific adverse events during this report period
CTC AE Attribution Code
SAE report submitted
Protocol Specific Adverse Event Evaluation
Any Treatment Related Adverse Events
CTC AE Attribution Code
SAE report submitted
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